The role of the multidisciplinary team meeting in an
antiretroviral treatment programme.

Abstract:

The importance of adherence in the management of patients on
combination antiretroviral therapy has been well documented. (1-6)
However, for sustainability of the overall programme adequate patient
'tracking' is required in order to understand where the
programme may be failing.

They found that more complex regimens were associated with
decreased adherence. Social and psychological factors reflecting
emotional adjustment to HIV/AIDS and provider support were associated
with improved adherence, as was access to institutional resources.
Personal attributes showed a mixed relationship; gender was not
consistently related to adherence, but younger age, minority status, and
a history of substance abuse were often associated with non-adherence.
An intervention search yielded 16 interventions employing a wide range
of behavioural, cognitive and affective strategies. However, evidence of
effectiveness of the interventions appeared to be poor.

According to Nischal et al., (7) studies have indicated that at
least 95% adherence to ART regimens is optimal. It has been demonstrated
that a 10% higher level of adherence results in a 21% reduction in
disease progression. The various factors affecting success of ART are
social aspects such as motivation to begin therapy, ability to adhere to
therapy, lifestyle pattern, financial support, family support, pros and
cons of starting therapy, and pharmacological aspects such as
tolerability of the regimen and availability of the drugs. Furthermore,
the regimen's pill burden, dosing frequency, food requirements,
convenience, toxicity and drug interaction profile compared with other
regimens need to be considered before starting ART. Lack of trust
between clinician and patient, active drug and alcohol use, active
mental illness (e.g. depression), lack of patient education, inability
of patients to identify their medications, and lack of reliable access
to primary medical care or medication may all contribute to inadequate
adherence.

Mehta et al. (4) found the following factors in an extensive study
on adherence: Adherence increases with age, except in the most elderly
(those aged over 75 years). (8) It is known that the very elderly often
have comorbidities such as vision, hearing or memory impairment as well
as multiple chronic illnesses. In several studies of patients with HIV
infection, chronic illness, mental illness, older age and male gender
were associated with decreased adherence. Lower socio-economic status
(SES) has been shown to be another contributor to decreased adherence.
(9) Socio-economic factors specifically related to decreased adherence
are unstable or poor housing, low income and low level of education. The
presence of psychiatric illness is commonly associated with decreased
adherence. (10) Other psychological factors affecting adherence among
the mentally ill are hostility, guilt, anxiety, paranoia and
grandiosity. (11) In contrast, in a prospective study of HIV-infected
individuals, adherent patients (defined as >80% adherence) had
significantly less depression than non-compliant patients. (12) Negative
attitudes about medications or illness may also interfere with patient
adherence. Among the mentally ill, reasons cited for not taking
medications were fear of addiction and the belief that medication use
was a sign of weakness. (13) Among HIV-infected patients, attitudes and
beliefs related to decreased adherence included the patient's
acceptance/ perception of disease, and perceived lack of benefit. (13)

THE POTCHEFSTROOM WELLNESS CLINIC

The ART clinic at Potchefstroom Hospital, known as the Wellness
Clinic, was accredited in November 2005 and currently manages >3 000
adults and children. There is a dedicated team with good continuity of
nursing, counselling and administration personnel but a high turnover of
doctors and allied health workers. Early in the clinic's history it
was decided to hold multidisciplinary meetings monthly, in order to
understand and deal with difficulties arising from the management of
patients on ART. The meetings started in January 2006 and are ongoing.

Patients with perceived problems affecting their optimal management
were identified by personnel at the Wellness Clinic during routine
consultations, and booked for the bi-weekly multidisciplinary team (MDT)
discussion. This team consisted of the physician and family physician
involved in the clinic, the unit manager, one nurse, the pharmacist, the
social worker and the dietician, one counsellor and a data collector.

THE ROLE OF THE MDT MEETING

An audit of the minutes of the 2006 MDT meetings was done. All the
minutes of the 2006 MDT meetings were examined and patients identified
together with the decisions made regarding them. The files of these
patients were drawn and the following variables were investigated:

* the original and most recent CD4 cell count and viral load (VL)

* reason for being on the MDT's agenda

* if there was an adherence issue, the reason for the poor
adherence

* whether support was available or not

* interventions decided upon

* the outcomes, where possible, of any interventions.

RESULTS

According to the minutes, 76 people were discussed. All were
adults, 39% were female, and their mean age was 38 years.

Of the files 13 could not be found for the audit, but reasons for
inclusion in the MDT meetings included the following: 6 patients (8%)
had virological failure with no apparent cause, as they had good pill
counts at each visit and were physically well. There was documented poor
adherence in 5 patients (7%), reflected in ongoing poor pill counts.
Forty-eight patients (63%) had defaulted treatment for varying lengths
of time. In 2 patients (3%) the reasons for inclusion were not clear
from the minutes or the files. Eight (11%) were included because of
alcohol abuse concerns and 7 (9%) for a variety of other reasons.

Since the group of defaulters was the largest group, it was
investigated in more detail. Some of the patients had more than one
reason for defaulting, while 13 patients had no real documented reason.
Work was cited as being a problem by 7 patients, especially with
contract workers being moved to different areas to work. Six patients
said that they had had financial problems. However, most of these were
already on disability grants. Alcohol played a role in 4 patients and a
variety of other reasons were given by the remaining 25. These included
parasuicide, mental retardation, hospital admission, felt sick from
pills/not feeling better, incarceration, lost in down-referral process,
transfer out, recent birth, painful legs, ashamed to come, domestic
upheavals and disputes, traditional medication, amputated leg, staff
confidentiality issues, cryptococcal meningitis, and tuberculosis
treatment (streptomycin).

In each case, a course of action was discussed and decided upon by
the multidisciplinary team.

INTERVENTIONS

The following were the most common interventions decided upon by
the MDT:

* buddy system, e.g. someone to accompany the patient to the clinic
visits

* social worker intervention

* individual interviews

* home visits

* link appropriate patients to Alcoholics Anonymous.

OUTCOMES

The results of these interventions were then analysed from the
available files.

Thirteen files could not be found. Four patients were confirmed as
lost to follow-up. Viral loads had decreased in 23 patients after the
interventions discussed above, while 17 patients' viral loads had
remained in the same range or increased. Viral loads had not been
properly done or recorded in 4 patients. Five patients had died, and 10
had other outcomes, e.g. ART stopped.

DISCUSSION

Following the MDT discussion and intervention, 23 of the available
63 files (36%) of patients who had been referred to the meeting because
of staff and performance concerns indicated that they were doing well at
the time of the audit, with virological and clinical stability. This
audit revealed that non-adherence or difficulty coping with the ART
programme was often caused by social and psychological problems. This
tends to be a difficult area for health workers to intervene in, and the
programmes have to rely on social welfare as well as community-based
groups as active partners.

Alcohol appears to have a small but significant influence, as was
found in larger studies on adherence. (4,6,9) More males than females in
the MDT group were encountering problems as a result of their alcohol
histories, but women were also affected.

Work-related absenteeism often applied to contract workers,
especially where artisans were moved for certain periods to other
provinces or countries. It remains a crucial part of general and
individual counselling that work be taken into consideration and that
medication amounts be negotiated, or referral letters written for
patients who plan to be away for a period of time.

Deaths are not always reported to the hospital, and a number of the
patients recorded as lost to follow-up may in fact have died.

Other ways to minimise loss to follow-up include optimised
'tracking' systems including 'defaulter tracing',
down-referrals to satellite clinics closer to home, and involvement of
other community-based organisations in tracing patients and doing home
visits.

The multidisciplinary team meeting at the Potchefstroom Wellness
Clinic did play a role in identifying and solving problems relating to
patients on ART. Since the team represents a core of interested people,
there is the potential to expand its role to discuss new policies, novel
interventions and issues in the clinic and the programme as they arise.

The challenge with providing an optimal service for patients is
that each person has their own story and many need individualised
attention. Without this understanding, and good relationships between
personnel and patients, the battle for optimal care within the ART
programmes cannot be won.

A few patient stories

A young woman who had started ART had had a boyfriend for 10 years.
He suddenly left her for another woman. She had repeated counselling but
became profoundly depressed, which influenced her adherence.

An older married couple were both patients at the Wellness Clinic
and on ART, but the husband was apparently being abused by his wife and
eventually died in hospital from an HIV-related infection. The wife
never came back in spite of intensive counselling and support from the
clinic personnel.

Two mothers insisted on their daughters taking traditional
medicines and stopping HAART. Both young women eventually returned to
the clinic in spite of this pressure.

A very problematic patient, who is still receiving HAART, returns
to the clinic with repeated STIs. She has been caught lying about her
pills and pill counts, comes and goes as she wishes, and is constantly
abusive towards clinic staff.